For CDR use only

PROGRAM NUMBER

Continuing Professional Education Prior Approval Request Form

-Live Programs- CPE Online Database: http://cdrnet.org/form-prior-approval

Program Title:

Program Provider:

Program Dates:

Estimated Number of RDs/DTRs Attending:

Program Location (City & State):

Target Audience: RDs DTRs Other

Is the program closed / invitation only? Yes No

Program Chair:

Contact Person (Receives Certificates of Attendance & additional materials):

Address:

Daytime Phone:

Fax:

Email:

As a Program Provider, I verify that the content of this continuing education program is education beyond the basic preparation required for initial entry into the profession for the Registered Dietitian and/or the Dietetic Technician, Registered.

Signature of Program Provider Date

120 South Riverside Plaza, Suite 2000, Chicago, Illinois 60606-6995 Note: Approval of CPEU hours acknowledges the need for an objective look at the information being presented. You may also fax it to 312-899-4772

Endorsement of presentations is not the function of CDR. Questions? Call 1-800-877-1600 ext. 5500 and ask for the Prior Approval contact.

Required Documentation: The following must be provided with this form

1. Educational objectives, describing anticipated outcomes for each session.

2. A timing outline, detailing all time spent in sessions, meals, breaks, etc. This is to ensure all hours are awarded for learning time only.

3. Information regarding the target audience.

4. Qualifications of speakers/presenters. These should be resumes or CVs.

Some Affiliate Dietetic Associations share the CPE approval responsibility with CDR. Please review the Prior Approval Review Contact List at http://cdrnet.org/prior-approval-review-contacts to determine where to submit your request form for review.

Journal Club Seminar/Lecture/Webinar Study Group Workshop Experiential Skills Development Poster Sessions Certificate Program Residency and Fellowship Programs Exhibits

Information on CPEUs Requested:

Number of Contact Hours: Exhibits: Posters:

Applicable Learning Need Code(s): (See Page 2 for LNC list)

CPEU Level: (You may choose multiple Levels)

Level 1: Little or no prior knowledge of subject

Level 2: General knowledge of literature and

professional practice in areas covered

Level 3: Thorough knowledge of literature and

professional practice in areas covered

For Continuing Professional Education Committee Use Only

Date: Maximum Hours:

Approved By: Exhibit Hours:

Disapproved By: Poster Sessions:

Learning Need Codes 1000 PROFESSIONAL SKILLS 1010 Career planning, Standards of Practice, Standards of Professional Performance, Scope of Dietetics Practice Framework 1020 Computer, electronic technology 1030 CPR 1040 Cultural sensitivity 1050 Ethics 1060 Foreign language, cultures 1065 Informatics 1070 Leadership, critical and strategic thinking 1080 Legislation, public policy 1090 Media skills 1100 Photography, video and graphic production 1110 Risk taking 1120 Time and stress management, life balance 1130 Verbal communication skills, presentations 1140 Written communication skills, publishing 2000 SCIENCE OF FOOD AND NUTRITION 2010 Botanicals, phytochemicals 2020 Composition of foods, nutrient analysis 2030 Food preservation, additives, irradiation 2040 Food science, genetically modified food 2050 Genetics 2060 Immunology 2070 Macronutrients: carbohydrate, fat, protein, fiber, water 2080 Microbiology, food toxicology 2090 Micronutrients: vitamins, minerals 2100 Nutritional biochemistry 2110 Physiology, exercise physiology 3000 NUTRITION ASSESSMENT & DIAGNOSIS 3005 Nutrition diagnosis 3010 Assessment methodology 3020 Assessment of target groups, populations 3030 Anthropometrics, body composition 3040 Food consumption, fluid balance 3050 Feeding, swallowing, dentition 3060 Laboratory tests 3070 Pharmacological, drug/nutrient, herbal interaction 3080 Physical: blood pressure, pulse, bowel sounds 3090 Screening parameters, methodology and surveillance 3100 Supplemental nutrients, botanicals 4000 WELLNESS AND PUBLIC HEALTH 4010 Community intervention, monitoring and evaluation 4020 Community program development 4030 Dietary guidelines, DRIs, Food Guide Pyramid, food labeling 4040 Disease prevention 4050 Epidemiology 4060 Exercise, fitness and sports nutrition 4070 Food security and hunger 4080 Government-funded food and nutrition programs 4090 Health behaviors: smoking cessation, stress management 4100 Social marketing 4110 Vegetarianism 4120 Life cycle (stages of life cycle) 4130 Pregnancy (stages of life cycle) 4140 Lactation (stages of life cycle) 4150 Infancy and childhood (stages of life cycle) 4160 Adolescence (stages of life cycle) 4170 Men’s health (stages of life cycle)

4180 Women’s health (stages of life cycle) 4190 Elderly nutrition (stages of life cycle) 5000 MEDICAL NUTRITION THERAPY 5010 Acute (care sites) 5020 Ambulatory (care sites) 5030 Home care (care sites) 5040 Long-term, intermediate, assisted living (care sites) 5050 Rehabilitation (care sites) 5060 Neonates (client population) 5070 Pediatrics (client population) 5080 Adolescents (client population) 5090 Adults (client population) 5100 Elderly (client population) 5110 Allergies, sensitivities (disease/disorder) 5120 Autoimmune diseases, arthritis, lupus (disease/disorder) 5125 Bariatric surgery 5130 Bone diseases, osteoporosis (disease/disorder) 5140 Burns (disease/disorder) 5150 Cancer (disease/disorder) 5160 Cardiovascular disease (disease/disorder) 5170 Critical care, trauma (disease/disorder) 5180 Developmental disorders (disease/disorder) 5190 Diabetes mellitus (disease/disorder) 5200 Disordered eating (disease/disorder) 5210 Dysphagia (disease/disorder) 5220 Gastrointestinal disorders (disease/disorder) 5230 Hematological disorders, anemia (disease/disorder) 5240 Hepatic disorders (disease/disorder) 5250 HIV/AIDS (disease/disorder) 5260 Hypertension (disease/disorder) 5270 Infectious diseases (disease/disorder) 5280 Nutrient deficiencies, failure to thrive (disease/disorder) 5290 Metabolic disorders, inborn errors (disease/disorder) 5300 Neurological: stroke, Alzheimer’s, dementia, Parkinson’s, spinal cord injuries (disease/disorder) 5310 Pregnancy complication (disease/disorder) 5320 Psychiatric disorders, anxiety (disease/disorder) 5330 Pulmonary diseases (disease/disorder) 5340 Renal diseases (disease/disorder) 5350 Substance abuse, alcoholism (disease/disorder) 5360 Transplantation (disease/disorder) 5370 Weight management, obesity (disease/disorder) 5380 Wound care (disease/disorder) 5390 Care planning, documentation and evaluation (nutritional care) 5400 Case management (nutritional care) 5410 Client protocols, clinical guidelines (nutritional care) 5420 Complementary care, alternative therapies (nutritional care) 5430 End-of-life care (nutritional care) 5440 Enteral and parenteral nutrition support (nutritional care) 5450 Feeding equipment, tube placement, adaptive utensils (nutritional care) 5460 Self-care management (nutritional care) 6000 EDUCATION, TRAINING AND COUNSELING 6010 Behavior change theories, techniques 6020 Counseling, therapy and facilitation skills 6030 Education theories and techniques for adults 6040 Education theories and techniques for children and adolescents

6050 Instructional materials development 6060 Learning needs assessment, learning plan development and evaluation 6070 Interviewing and listening skills 6080 Training, coaching and mentoring 7000 BUSINESS AND MANAGEMENT 7010 Business plan development 7020 Conflict management 7030 Contract management 7040 Consultation 7050 Customer focus 7060 Emergency and disaster management 7070 Entrepreneurship, private practice 7080 Financial management 7090 Human resources management, labor relations 7100 Institution/regulatory policies and procedures, HCFA, OBRA, Joint Commission, NCQA, OSHA, USDA 7110 Legal issues, malpractice 7120 Marketing 7130 Managed care 7140 Materials management 7150 Negotiation 7160 Quality management 7170 Reimbursement, coverage 7180 Strategic planning 7190 Supervision, crisis management 7200 Team building 7210 Sales, merchandising 8000 FOOD SERVICE SYSTEMS AND CULINARY ARTS 8010 Child and adult food programs 8015 Cultural/ethnic food and culinary practices 8018 Environmental, agricultural and technologic influences on food systems 8020 Equipment management 8030 Facilities layout, planning and design 8040 Food safety, HAACP and sanitation 8050 Food distribution and service 8060 Culinary skills and techniques 8070 Food production, quantity purchasing 8080 Food styling and food presentation 8090 Menu planning and development, nutrient analysis 8100 Food and recipe development and modification 8110 School foodservice 8120 Sales, merchandising 8130 Sensory perception and evaluation of foods and ingredients 9000 RESEARCH AND GRANTS 9010 Data analysis, statistics 9020 Evaluation and application of research 9030 Outcomes research, cost-benefit analysis 9040 Proposal development, grant applications 9050 Publication, communications of research outcomes 9060 Research development and design 9070 Research instruments and techniques